To emphasize the specialization of psychosomatic medicine, I will take up the subject of eating disorders. I will address epidemiological, etiological, patho-physiological, patho-psychological and therapeutic aspects of eating disorders. I will show the studies of Kyushu University, Tokyo University and a research group supported by the Ministry of Health and Welfare. According to our epidemiological studies, the estimated total number of eating disorders patients who visit Japanese hospital in 1992 is 6,000. The Incidence of eating disorders in hospital patients is 4.9 per 105 general population. But the incidence in school girls is much higher. Diagnostic criteria were established. In etiological research, studies on the effect of neuro-peptides have been performed. As to patho-physiological studies, there are many studies related to eating disorders in endocrinology, gastroenterology and immunology. In patho-psychological research, a Japanese version of EDI (Eating Disorder Inventory) was made. Transcultural studies on the relationship between child abuse and eating disorders were also performed. The research group published a manual on treatments of eating disorders. Among a variety of treatments methods, cognitive behavior therapy and family therapy are currently attracting attention. The effect of Selective Serotonin Reuptake Inhibitors (SSRI) on bulimia was studied.

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The purpose of this paper is to discuss the generality and speciality of psychosomatic medicine, and to study the field that the specialists in psychosomatics should engage in. We distributed a questionnaire to 109 internists who had been working in our department for more than 6 years. They were not specialized in psychosomatics and had worked for more than 2 years in our ward where psychosomatic patients as well as other patients were being treated. Seventy-five internists were involved in this study (68.8%) We categorized the participants as follows. Group A was composed of 60 internists who had experienced treating psychosomatic patients. This group was further subdivided into 2 groups ; group A1 consisting of 46 internists who had been main doctors of psychosomatic patients for more than 3 weeks, and group A2,consisting of 14 internists who had been substitute doctors of psychosomatic patients for less than 3 weeks. Group B, on the other hand, was made up of 15 internists who have never treated any psychosomatic patient but became familiar with psychosomatic approaches through observation. More than 90% of internists in both groups of A and B agreed that many patients who consulted them needed some psychosomatic approaches in their treatment. Likewise, about 90% of internists in group A considered that experiencing psychosomatic approaches can be very useful in the general medical practice. All internists in both groups recognized the necessity of establishing the department of psychosomatics as a special field of internal medicine. We also inquired from the participants about the kinds of patients they would like to refer to specialists of psychosomatics. About 80% of internists in both groups wanted to refer patients with somaticovisceral disorders in which the symptoms are influenced strongly by psychological factors. About 50% of internists in each group also agreed to refer patients with chronic and intractable diseases on which psychological factors may have such an influence. About 60% of internists in group A also wanted to refer patients with intractable and persistent symptoms to specialists for confirming if the symptoms of patients are influenced by psychological factors or not. However, only 40% of internists of group B had a similar opinion. In contrast, about 70% of internists in group B would like to refer patients with psychological complaints and equivocal symptoms, while only 50% of internists in group A agreed. For further understanding of the psychological approaches, more than 90% of internists in both groups of A and B think that it is necessary to include lectures about psychosomatics in the medical education and post graduate training. On the other hand, about 70% of internists in group A believe that they could apply behavior therapy to clinical cases up to certain extent and they agreed that a good way to learn psychosomatic approaches is to be the main doctor of some psychosomatic patients. These results suggest that patients suffering from somaticovisceral disorders with underlying psychological problems can be easily identified and referred to specialists of psychosomatics if the general physicians are given sufiicient knowledge about psychosomatic medicine.

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Once a week a consultation team of 3-5 members visited all ten 300-bed wards in the Tokyo Metropolitan Ohkubo Hospital. Between April, 1994 and March, 1995,we consulted 253 cases, a consulting ratio being 6.6% of the 3818 total patient population. The 253 patients were almost equally male and female : ages from 17 to 98,145 of whom were in their sixties and seventies. 16.3% (42/258) were from Nephrology which includes hemodialysis, 10.8% (27/251) from Neurosurgery including cerebral vascular disease, 7.5% (41/547) from Surgery, and 6 .9% (88/1275) from Internal Medicine. Among the cases were diseases such as malignancy (45) , chronic renal failure on hemodialysis (29) , and cerebral vascular disease (20), as well as functional symptoms (23) . The contents of the requests were how to respond to attempted suicide, insomnia, disquietude, uneasiness, anorexia, behavioral problems, and other psychiatric physical symptoms. Psychological assessments revealed organic psychosis, symptomatic psychosis, alcoholic symptoms, depressive state, depression, schizophrenia, neuroses (include somatoform disorder and anxiety disorder) , psychosomatic disease, epilepsy, anxiety about symptoms, anticipatory anxiety, insomnia, problems of personality (include personality disorder) and current behavior problems. Doctors consult team members directly (152/158) . When we visit the ward, the nursing staff consulted our team mainly about behavioral problems (66/83). Their questions provided us with an opportunity to discuss and define psychosomatic issues and to assist the nursing staff's ability to resolve the problems as they arose. Since illness and disease are complex human phenomena, the visits to the wards were enlightening to us as well as the nursing staff. The psychiatrist was in charge of the cases who were aged and assessed as delirium or depressive state. A clinical psychologist was in charge of the cases with requests to assess intelligence or personality by psychological tests and interviews, to support terminal patients, to help with how to treat patients, and to do psychotherapy. A psychosomatic physician was in charge of the cases who had varied physical symptoms in which psycho-social factors participated. The generality of psychosomatic medicine is for the staff to give psychosomatic care to all patients. The speciality of psychosomatic medicine is to promote treatments for the patients who have a pronounced psychosomatic background. To make use of psychosomatic suggestions fdr inpatients at a general hospital, it is important to have close collaboration between the consultation team and medical staff.

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In order to spread psychosomatic ideas in general clinical practice, objective criteria are needed to make proper use of the generality and speciality of pychosomatic medicine according to the pathology of individual patients. From this point of view, we investigated our stepwised program for asthmaic patients and advocated a model of psychosomatic treatment. The subjects were 200 patients (83 males and 117 females) with bronchial asthma. The severity of the disease was classified into four degrees (A to D) , considering frequency of asthmatic attacks, necessity for medication, and restriction of daily life : A (no need for extra visits and no restriction of daily life), B (occasional extra visits for treatment but no need for continuous steroids) , C (need for frequent drip infusion or continuous use of oral steroids) , and D (highly restricted daily life because of continuous attacks) . Stepwise psychosomatic therapies were combined with ordinary physical treatment. Usual anti-asthmatic medication was applied to all the subjects. The patients in classes B, C, and D were given general information about asthma and instructed self-monitoring with peak-flow meters. Autogenic training and transactional analysis were performed in groups for those in calsses C and D. For those in class D, individual psychotherapy and family therapy were also done. Factors significantly associated with severity were onset age (lower) , duration (longer) , and psychological character (alexithymic) . All of 79 cases in class A at the beginning of the treatment remained in the same class after the treatment. Outcome of 121 cases in classes B, C, and D was as follows : improved 61.9%, no change 30.6%, deteriorated 2.5%, and dead 5.0%. General psychosomatic treatment mainly consisted of education and instruction is necessary and effective in asthmatics regardless of pathophysiology. Specialized psychosomatic treatment should be selected according to the class of physical severity. Our stepwised psychosomatic approach according to pathophysiology might be a model for not only bronchial asthma but other chronic physical diseases as well.

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The significance of psychosomatic treatment in non-ulcer dyspepsia (NUD) , a common disease, was investigated. One group of patients with NUD were treated as outpatients at a general internal medicine clinic located in a downtown of Fukuoka city and were clinically 'light' NUD cases. Another group with NUD was treated at the Department of Psychosomatic Medicine of Kyushu University Hospital and consisted of 'serious' NUD cases. All patients were diagnosed multiaxially, as functional disorders of the upper digestive system and psychiatric disorders. These two 'light' and 'serious' NUD groups were compared regarding the types of psychological disorders as well as the types of symptoms. Based on the results of our study, it was elucidated that in the treatment of NUD, primary care, especially regarding both functional disorders of the upper digestive system and psychiatric disorders, is very important. Moreover, NUD, regardless of its seriousness and the stage of the illness was found to be effectively treated by an adequate program of care that is based on a through diagnosis that includes a psychiatric evaluation.

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The long range goal of psychosomatic medicine is to clarify interactions between higher brain function and peripheral organs. To discuss the future direction of psychosomatic medicine, we review our experiment that heat shock cognate protein (HSC 70 messenger RNA increases in some of stress-vulnerable organs ; brain and gut, under psychophysiological stress. In control rats, cerebral HSC 70 mRNAs were constitutively expressed while gastric HSC 70 mRNAs were scarcely identified. Restraint-water immersion stress significantly increased the level of cerebral HSC 70 mRNAS for 6 hrs and 12 hrs. Hypothermia, induced by water immersion, excluded a possible role of hyperthermia in inducing HSC 70 mRNA. Our results point to a crucial cytoprotective role for families of heat shock proteins in stress-vulnerable brain-gut link in mammals under psychophysiological stress. Active induction of molecular biology is useful for psychosomatic research.

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Innovation in educational curriculums for medical students before graduation is currently being promoted at Kyushu University as well as other universities. A discussion of our role in medical education and the methods used to teach psychosomatic medicine would be timely. First, we present the current situation with regard to curriculums for psychosomatic education. Second, we examine and assess the bed-side teaching program using questionnaires filled out by the students. Finally, problems and solutions are discussed. The educational objectives of our department are 1) to understand the relationship between the body and mind by learning typical pychosomatic diseases, and 2) to understand holistic medicine by learning psychosomatic approaches. The bed-side training programs in our department are experiential rather than didactic. Students undergo what patients experience on the ward, such as psychological testing, psychophyisiological testing, biofeedback treatment, transactional analysis, autogenic training, occupational therapy, and interview. Questionnaires filled out by the students at the end of training showed that our educational aims were adequately attained. Moreover, they felt that the doctor-patient relationship was important and that they viewed diseases differently, that is from a psychosocial viewpoint. Some students indicated that the training gave them an opportunity to consider themselves. The following problems were encountered. l) Lecture is still the main style of education. 2) The completion of a case report is considered the objective of bed-side teaching. 3) There are too few teaching staff. 4) An organ-oriented educational program may restrict the conception of holistic medicine. 5) Limitations to the extent students can participate in diagnosis and treatment, especially psychological aspects. 6) Assessment of the students and the educational methods. In summary, educational programs that specialize in psychosomatic medicine as we do are considered to provide not only special learning about psychosomatic diseases but also about the basic concepts of comprehensive medicine. It is important for specialists in psychosomatic medicine to positively participate in medical education, since that will lead to further development of psychosomatic medicine.

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In the University of Tokyo, we have performed the psychosomatic medical education for all medical students since 1987. The purpose of this paper is to discuss the efficacy and the significance of the psychosomatic medical education. In this paper, we would like to emphasize the importance of bedside teaching (BST) in a small group. The aim of BST is the training of psychosomatic methods for diagnosis and treatment by using oneself as the teaching materials. One-week schedule of BST includes the interview training, the presentation of eating disorder patients, the practice of psychological tests, the intake interview of outpatients, the experience of autogenic training and play therapy using a miniature garden, the practice of gestalt therapy, behavior therapy (biofeedback therapy) and transactional analysis and others. Subjects of this study were 675 medical students (619 men and 56 women) for seven years from 1987 to 1993. We summed up and took the statistic of all free-style reports. The results of this study indicated that the experience learning was useful for understanding the psychosomatic medical model, and that many students recognized the needs of the holistic medical approach for any clinical department. The goal of the psychosomatic medical education is to introduce a psychosocial viewpoint in medicine in addition to biological one, and to cultivate the attitude of holistic medical approach including doctorpatient relationship for all medical students. For this purpose, it might be needed to make a guideline of psychosomatic medical education and to establish a psychosomatic medical department in all medical colleges.

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A questionnaire was sent to a total of 80 university hospitals and medical colleges in Japan to find the present state of psychosomatic education. Effectiveness of the education on psychosomatic medicine was also examined. The content of our research included 4 areas, i.e., (1) the kind of lectures, (2) teaching hours in a year, (3) at what year of medical school they are given, and (4) which department was in charge. Forty-nine institutions out of 80 (61.3%) answered the questionnaire. Forty-seven of them have educational programs specific to psychosomatic medicine. The maximal hours of the lectures in six years were 66 hours and the minimum was 1 hour (mean was 11 hours and 20 minutes) . Most of the facilities gave the lectures at the 4 th year. A department of psychiatry was in charge in the most of the facilities, which was followed by departments of internal medicine and psychosomatic medicine. Effectiveness was proven because significant difference was found in diagnosis of symptoms and the understanding of relationships between psycho and soma, holistic medicine and QOL was facilitated.

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A training course in medical interviewing has been introduced to medical undergraduates in Toyama Medical and Pharmaceutical University since 1988. This training program is based on Microcounseling Training (MCT) reported by lvey. The course has been performed as a 4-hour single session of miniworkshop. Four to 6 trainees studied the basic attention skills in each session. The skills include attending behavior, introduction, questioning, Iistening, summarization, focusing and integration of the skills. Short lectures, demonstrations, role plays, feedback and discussion are used for the training in the session. The procedures of the training course are stated precisely and concretely in this report.

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